Pathology of the inferior & superior wisdom teeth

1. Medical history
 Necessary because useful information may be found concerning the general health of the patient. This
information determines the preoperative preparation and the postoperative care instruction.

2. Clinical examination
 The degree of difficulty of access to the tooth is determined.
 When the patient cannot open his mouth because of trismus due to inflammation the trismus is
treated first and the extraction postponed.
 In certain cases , when the canine is impacted, buccal\palatal protuberance may be observed during
palpation or even inspection, which suggests that the impacted tooth is located underneath.
 The adjacent teeth are examined and inspected to insure their integrity during manipulation with
various instruments during the extraction procedure.

3. Radiographic examination
 Provides us more information to program and correctly plan the surgical procedure. Its includes: position
and type of impaction, relationship of impacted tooth to adjacent teeth, size & shape of impacted tooth,
depth of impaction in bone, density of bone surrounding the tooth and the relationship of the impacted
tooth to various anatomic structure (mandibular canal, mental foramen, maxillary sinus)
 Periapical, panoramic, occlusal, CBCT

4. Indication for extraction- some believe that the removal of impacted teeth is necessary as soon as their
presence. On the other hand, if the teeth are asymptomatic there is no need to remove them because it can
cause serious local complications. (Nerve damage, fractures of maxillary tuberosity etc.). If the impacted
teeth are already caused problemeverybody agrees that they should be removed:

 Localized or generalized neuralgias of the head- Variety of symptoms

related to headaches and various types of neuralgias. In this case, the pain may be due to pressure
exerted by the impacted tooth where it comes in contact with many nerve endings. The pain may be
relief after extraction.

 Pericoronitis- an acute infection of the soft tissues covering the semi-impacted tooth and the associated
follicle. This condition may be due to injury of the operculum (soft tissue covering the tooth) by the
antagonist 3rd molar or because of entrapment of food under the operculum, resulting in bacterial
invasion and infection of the area. After inflammation occurs, it remains permanent and causes acute
episodes from time to time. It present as severe pain in the region of the affected tooth, which radiates
to the ear, TMJ and posterior submandibular region. Trismus, difficulty in swallowing, submandibular
lymphadenitis, rubor and edema of the operculum are also noted.
A characteristic of pericoronitis is that when pressure is applied to the operculum, severe pain and
discharge of pus are observed.
Acute pericoronitis is often responsible for the spread of infection to various regions of the neck and
facial area. (slide 10)

 Production of caries- entrapment of food particles and bad hygiene, due to the presence of the semi-
impacted tooth, may cause caries at the distal surface of the 2 nd molar, as well as on the crown of the
impacted tooth itself.

 Decreased bone support of 2nd molar- the well-timed extraction of a swmi-impacted tooth presenting a
periodontal pocket ensures the avoidance of resorption of the distal bone aspect of the 2 nd molar, which
 would result in a decrease of its support.

 Obstruction of placement of a partial\complete denture- impacted teeth of edentulous patients can

erupt towards the residual alveolar ridge, creating problems when applying a prosthesis.
The localization of the tooth is often observed after its communication with the oral cavity and the
presence of pain and edema.

 Obstruction of the normal eruption of permanent teeth- impacted teeth and supernumerary teeth often
hinder the normal eruption of permanent teeth, creating functional and esthetic problems.

 Provoking or aggravating orthodontic problems- lack of room un the arch is possible the most common
indication for extraction primarily of impacted and semi-impacted 3 rd molars.

 Participation in the development of various pathologic conditions- often cystic lesions develop around
the crown of the tooth and are depicted on the radiograph as different sized radiolucency. These cysts
may be large and may displace the impacted tooth to any position in the jaw. This lesion must be
removed together with the impacted tooth.

 Destruction of adjacent teeth due to resorption of roots- it begins with resorption of the distal root and
eventually can destroy the entire tooth.

5. Therapeutic attitude in the case of the inferior wisdom teeth- established after a clinical & radiological
examination which will specify :
 Depth of inclusion, crown shape and roots
 Direction of the longitudinal axis of the molar
 The ratios and position of the wisdom molar in relation to the 12YO molar and the ascending branch of
the mandible.
 The importance of accidents and complications caused by the included lower wisdom tooth.

Clinical situation the lower wisdom tooth can produce:

- didn’t cause accidents or complications

- mild inflammatory disorders. Such as congestive or suppurative pericoronitis
- severe inflammatory complications
- various non-inflammatory complications.
In acute congestive pericoronitisoral irrigation with antiseptic solutions or treatment with physical
agents is recommended (ultrasound, diathermy, low-intensity laser therapy). Anti-inflammatory
and analgesic drugs may be used to combat pain and congestion.

In suppurative acute pericoronitissurgical treatment is indicated by:

- Drainage of the peri-coronary sac from under the mucous membrane cap. Can be done through
an incision that affects all layers of the peri coronal sac along its entire length, the wound being
kept open with the help of an iodoformed mesh.
i. Under Local anesthesia  incision of 1.5cm is made with anteroposterior direction,
using a scalpel, plastic scissors, or electrocautery.
ii. The incision will cover the entire thickness of the mucous membrane up to the wisdom
tooth. The wound is them irrigated with an antiseptic solution and drainage is done with
an iodoformed mesh.
iii. General medication, analgesics and anti-inflammatory drugs are administered, thus
draining the suppuration under the mucous membrane capallowing the eruption of
the wisdom molar.
 - Operculectomy : consist in the excision of the fibromucosal cap that covers the crown of the
wisdom tooth. It will be performed only after the remission of inflammatory\suppurative
phenomena.

Indications Contraindications
Thin mucosal cap, covering the occlusal face Insufficient retromolar space
of the wisdom tooth\ submucosal inclusion Abnormalities in shape\volume of the crown
and\or roots of the wisdom tooth
Vertical inclusion Thick mucous membrane cap
Sufficient space on the arch for the Partial or total bone inclusion
subsequent eruption. Ectopic inclusions

The technique can be used with scalpel, electrocautery and laser (slides 25-30)
i. After LA an incision is made that circumscribes the crown of the 3 rd molar. The incision
starts from the disto-lingual face of the 2 nd molar, back to the limit of the horizontal
portion of the retromolar space and returns along the buccal slope, up to the disto-
buccal face of the 2nd molar. (should follow the area with greatest amount of attached
gingiva. May be directed disto-lingually or disto-facially)
ii. After sectioning, the fibro mucosal cap is lifted and the occlusal face and a portion of the
surrounding wisdom tooth crown are then released. Then excised and the remnants of
the peri coronary sac around the 3 rd molar crown are removed.
iii. The wound is irrigated with an antiseptic solution and a strictly marginal electrocautery
of the remaining fibromucosa can be performed without touching the dental crown, the
edges of the wound are then pushed as far as possible to the tooth package and are
maintained with iodoform mesh covering the entire wound surface.
o Electrocautery- involves the intentional passage of high frequency waveforms or currents,
through the tissues of the body to achieve a controllable surgical effect. The passage of current
into tissue cause cellular fluid to turn into steam, bursting cell wall and disrupting the structure.
It has significant advantages over steel scalpel based on incision time, blood lose, early posy-
operative pain and analgesia. Loop electrode is used in a range of 1.5-7.5 mHz in a continuous
brushing method.
6. Appropriate timing for removal of impacted teeth- most suitable is when the patient is young thus avoiding
some complications and undesirable situations that could get worse with time. Also, young patient deal with
the overall surgical procedure and stress well , and present fewer complications and faster postsurgical
wound healing compared with older patients. Moreover, its easier to remove bone cause its less dense and
hard.

7. Steps of surgical procedure :

a) Incision and reflection of the mucoperiosteal flap
b) Removal of bone to expose the impacted tooth
c) Luxation of the tooth
d) Care of the post-surgical socket and suturing of the wound

 Main factors for a successful outcome to the surgical procedure are:

o Correct flap design – which must be based on the clinical and radiographic examination (position
of tooth, relationship of roots to anatomic structures, root morphology)
o Ensuring the pathway for removal of the impacted tooth- with as little bone removal as possible.
This is achieved when the tooth is sectioned and removed in segments, which causes the least
trauma possible.

8. Extraction of impacted inferior wisdom teeth (slides 35-77)

 The technique for its removal is determined by its localization. Depending on the direction of the crown :
(Archer and Kruger)
1) Mesioangular
2) Distoangular
3) Vertical
4) Horizontal
5) Buccoangular
6) Linguoangular
7) Inverted
It can also be classified according to their depth of impaction, proximity to the 2 nd molar, the distance
between the distal aspect of the 2nd molar and the anterior border of the ramus of the mandible.

Pell and Gregory:

The depth of the impaction is concerde:
1) Class A: the occlusal surface of the impacted tooth is at the same level as or a little below that of the
2nd molar
2) Class B: the occlusal surface of the impacted tooth is at the middle of the crown of the 2 nd molar or
at the same level as the cervical line.
3) Class C: the occlusal surface of the impacted tooth is below the cervical line of the 2 nd molar.

The distance to the anterior border of the ramus : (slide 38)

1) Class 1 : the distance between the 2 nd molar and the anterior border of the ramus is greater than the
mesiodistal diameter of the crown of the impacted tooth so that the extraction does not require
bone removal from the region of the ramus.
2) Class 2: the distance is less nd the existing space is less than the mesiodiatal diameter of the crown
of the impacted tooth.
3) Class 3: there is no room between the 2 nd molar and the anterior border of the ramus, so that the
entire impacted tooth or part of it is embedded in the ramus. (more difficult during extraction
because it requires removal of large amount of bone and there is a risk of fracturing the mandible
and damaging the inferior alveolar nerve.

* the number of roots and the relationship to the mandibular canal are taken into consideration.

Types of flaps
 Triangular flap (L-shape):
- When we used: impaction is deep, to ensure a satisfactory surgical field or when the impacted
tooth conceals the roots of the 2nd molar, the incision may continue along the cervical line of the
last tooth while the vertical incision begins at the distal aspect of the 1 st molar.
- How: the incision begins at the anterior border of the ramus(external oblique ridge) with special
care for the lingual nerve and extends as far as the distal aspect of the 2 nd molar, while the
vertical releasing incision is made obliquely downwards and forward, ending in the vestibular
fold.

 Envelope flap (horizontal) :

- When we used: when impaction is relatively superficial.
- How: the incision begins at the anterior border of the ramus and extends as far as the distal
aspect of the second molar, continuing along the cervical lines of the last 2 teeth and ending at
the mesial aspect of the first molar .

Steps removal of bud of impacted mandibular 3 rd molar (47-50)

- Triangular incision with scalpel 0.15 blade
- Mucoperiosteal flap is reflected from the distal aspect of the 2 nd molar, continuing along the incision
posteriorly as far as the anterior border of the ramus
- Removing the bone that covers the tooth until the entire crown is exposed with round bur.
- If the roots of the tooth have not yet developed, the tooth will roll around inside the alveolar crypt
during the elevation attemptthe extraction is difficult
- That is why a pathway for removal must been sure, by removing sufficient bone from the buccal and
distal aspects of the crown of the tooth(guttering technique), so that its elevation from the socket is not
hindered.
- After exposing the impacted tooth sufficiently, the straight elevator is placed in the mesial region and
the tooth is elevated with rotational movement.
- When the extraction is complete, the follicular sac (usually on the distal aspect of the 2 nd molar) and
bone fragments that may be present in the socket are removed.
- Examination of the bone margin to make sure they are smooth, if not bone file or a special bur may be
used to smooth the bone.
- The area is irrigated with saline solution and the wound is sutured.
- The 1st suture is placed at the corner of the flap to ensure correct repositioning of the flap, while the rest
are placed along the posterior and vertical incisions.
- Postoperative instructions are given to the patient (oral & written). The procedure for care of the wound
is the same as that all cases of impacted teeth.
- Sutures are removed days later

Extraction of impacted 3rd molar in horizontal position: (56-60)

The tooth may be superficial or deep in the bone and the crown is close to the distal aspect of the 2 nd molar.

- Horizontal incision with scalpel 0.15 blade and the mucoperiosteal flap is reflected
- The bone covering the tooth is removed using a round bur and the area is irrigated with saline until the
crown is entirely exposed
- Grooves created vertically to the long axis of the tooth using fissure bur, at the cervical line of the tooth-
to separate the crown from the root. Make sure the groove is not too deep because the mandibular
canal is close and there is a risk of injuring the inferior alveolar nerve
- Straight elevator in placed in the groove to separate between crown & root with a rotational movement.
- The crown is remove using the same elevator with rotational movement upwards.
- The root is easily removed using straight or angled elevator whose blade end is placed in a purchase
point creating on the buccal aspect of the root. If the tooth has 2 roots: remove 1 st the distal root and
then the mesial root. Separation between the roots needs to takes place during the separation from the
crown, if not then it must be carried out later, cause during the attempt to extract both roots at the
same time there is a risk of fracturing the root tips, especially if they present curvature.
- Smoothing the bone
- Irrigation with saline
- Sutures: 1st is placed at the distal aspect of the 2 nd molar and the rest are placed at the interdental
papillae and the posterior end of the incision.

Extraction of 3rd molar with mesioangular impaction: (64-69)

This tooth presents inclination of the crown mesially, to a grater or lesser degree, so that the mesial cusps
are in contact with the distal aspect of the 2 nd molar. Sectioning of the tooth is require when it has
mesioangular impaction and the crown is just below or below the cervical line of the 2 nd molar.

- Horizontal incision an reflection of the mucoperiosteal flap. Reflecting begins at the interdental papilla at
the mesial aspect of the 1st molar and continues posteriorly , along the incision as far as the anterior
border of the ramus.
- Removing of the bone that covers the tooth until the crown is exposed with round bur.
- Guttering technique is used with fissure bur for removing sufficient bone on the buccal and distal aspect
of the tooth:
o Vertical groove is made on the crown as far as the intraradicular bone
 o Sectioning is achieved using straight elevator, which after being placed in the groove is rotated
and separates the roots. This separation allows for limited bone removal, thus causing less
trauma and faster completion of the surgical procedure
- If the tooth is single rooted- the mesial portion is removed first , while the remaining portion is then
luxated.
If the tooth has 2 roots- may be separated and each root may be extracted in the easiest direction,
depending on its curvature.
- Care of socket , suturing od the wound in the same way as the other

Extraction of 3rd molar with distoangular impaction

located beneath the anterior border of the ramus with a fair amount of bone above its crown, while its roots
are inclined some what near the distal root of the 2 nd molar.

- The technique is similar to mesioangular impaction, the difference is the separation of the tooth, which
is performed so that its removal can be achieved with minimal bone removal
- The distal portion of the crown is sectioning using fissure bur and removed, while the remaining segment
of the tooth is then luxated, after placing the elevator at the mesial aspect of the tooth.
- Care of socket , suturing od the wound in the same way as the other

Extraction of impacted 3rd molar in edentulous patient

- The technique for creation of flap and removal bone are the same as those used for other cases of
impacted teeth.
- The 2nd molar is often missingtooth sectioning is not necessary because it may easily be extracted
using either the elevator or tooth forceps, after the bone surrounding the tooth has been removed.

9. Extraction of impacted superior wisdom teeth

Its difficult because of insufficient visualization of the area and limited access.
Classification:
A. according to Archer: the tooth usually present with mesial\ distal inclination with the occlusal surface
positioned buccally (79)
- mesioangular
- distoangular
- vertical
- horizontal
- linguoangular
- inverted

B. according to the depth of impaction compared to the 2 nd molar: (80)

- Class A: the occlusal surface of the impacted tooth is at approximately the same level as the
occlusal surface of the 2 nd molar
- Class B: the occlusal surface of the impacted tooth is at the middle of the crown of the adjacent
2nd molar
- Class C: the occlusal surface of the impacted tooth is below the cervical line of the adjacent molar
or even deeper, contiguously or even above its roots. *Extraction
of this category entails the removal of large amount of bone, limited access and the risk
of displacing the impacted tooth into the maxillary sinus.

Types of flaps (83-84)

 Triangular flap (L-shape):

- How: the incision begins at the maxillary tuberosity and extends as far as the distal aspect of the
2nd molar, continuing obliquely upwards and anteriorly to the vertical fold.
 - When impaction is deep and a satisfactory surgical field is necessary or when the impacted tooth
covers the roots of the 2nd molar buccally, then the vertical incision may be made at the distal
aspect of the 1st molar.

 Envelope flap (horizontal) :

- How: the incision begins at the maxillary tuberosity and extends as far as the distal aspect of the
2nd molar, continuing buccally along the cervical lines of the last 2 teeth, and ending at the
mesial aspect of the 1st molar.

Removal of bone – after reflection of the flap the bone may be thin and spongy so we may remove it from
the buccal surface using sharp instruments. If the buccal bone is dense and thick then the removal is
achieved by surgical bur.
- After incision, the mucoperiosteal flap is reflected and the buccal bone is then removed until the entire
crown of the impacted tooth and part of its roots are exposed.
- Because extraction of the tooth in segments is not indicated, sufficient space must be created around its
crown to be able to luxate the tooth.
- Thus, using a straight or double-angled elevator on the mesial aspect of the tooth, always buccally, the
tooth is luxated carefully, posteriorly, outwards and downwards.
- Care of the wound and suturing are performed in the same way as described for all other cases of
impacted teeth.

CLINICAL SIGNS AND DIAGNOSIS OF DENTAL INCLUSION

Depending on the type of tooth included, the symptoms of dental inclusion may or may not be specific.

Most of the time, the clinical signs of dental inclusion go unnoticed for the individual and his family, sometimes even
for the doctor.

Either it is externalized by the secondary pathological phenomena that it triggers, or the inclusion is discovered
accidentally, on the occasion of a radiological examination of the neighboring regions.

symptoms:

 the absence of the permanent tooth from the arch after a longer time elapsed from its normal eruption
period;

 the presence on the arch of the temporary tooth (accompanied by the lack of a permanent tooth);

 the existence of a space on the arch;

 the presence of tremors and diastemas;

 displacements, rotations and migrations of the neighboring teeth (including the upper canine, the upper
lateral incisors are in distal inclination);

 inflammatory processes of the mucosa (pericoronitis and gingiva-stomatitis);

 the presence of chronic fistulas, without therapeutic response;

 on inspection and palpation, a vestibular or oral deformity can be found, a deformation of hard consistency
that could be the seat of the included tooth (bone deformities).

\
The main data on dental inclusion are provided by the radiological investigation

Local Disorders associatedwith impacted 3rd molar:

 a) Topography of the eruption site and molar morphology included:

• inclusion at the normal place of eruption;

• ectopic inclusion with eruption in the angle of the mandible, ascending branch, etc.;
• eruption in abnormal position with inclinations in the axis (mesial, distal) with lingual or vestibular
deviation;
• globular crowns associated with lack of space and eruption in abnormal position;
• the relationship with the second molar.
 b) The existence of the pericoronal space, virtual cavity, around the crown of the tooth, which,
under the action of various factors, can turn into a real cavity.
 c) The mucosal cap (operculum) which represents the main favoring element, in the occurrence of
accidents and septic complications of the inclusion of the lower wisdom tooth.
This cap makes a "pocket", and in the space between the occlusal surface of the included molar and
the mucosa, by retaining food debris, optimal conditions for the development of pathogens
(especially anaerobes) are created, favoring the appearance of septic complications.
The mucous membrane cap may be thin, stretched, covering the occlusal surface as a "table face"
or may be thick, covering the occlusal face as a "curtain".
 d) Opening the follicular sac in the oral environment and grafting the septic process from the 12-
year-old molar.
General factors:
General factors include the infection of the follicular sac, which can occur in a general, endogenous
way, especially during diseases that lower the immune threshold- septic- in note book